Software-as-a-Service (SaaS) Relieves Medicaid Claims-Processing Headaches

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Cost pressures on today’s health plan organizations are relentless. While these insurers have always sought to maximize their profitability, their plans offered through the Affordable Care Act appear to have been underpriced for the risk they assumed. In fact, according to a recent article in The Wall Street Journal, non-profit Blue Cross and Blue Shield insurers paid out a higher share of individual-plan premiums than they took in from premiums in the first nine months of 2015.

Cost-containment by outsourcing non-core business processes

While these health plans will inevitability re-price plans to reflect risks, their cost-consciousness will continue to help regain profitability. One way for health plans to achieve higher margins lies in more efficient back-office operations. Legacy in-house platforms may well obstruct the kinds of scalability and flexibility health plans need to handle new product types and expanded customer volumes. That’s why more health plans are opting for the type of business processing outsourcing (BPO) Dell Services provides.

Community Health Plan of Washington: a success story

The Community Health Plan of Washington (CHPW), is among the state’s best Medicaid payers. It has nearly 300,000 Medicaid members and many service providers across almost 600 primary-care sites and more than 100 hospitals. Due to lower Medicaid reimbursement rates than commercial insurers, CHPW’s core task of building a network of high-quality health providers can be tough.

Years ago, CHPW’s claims processing was a headache for both providers and employees, because the plan relied on a sister organization for managing claims and payments. But, as Alan Lederman, CHPW’s chief administrative officer, explains, “The relationship was tense because we didn’t have access to all our data, and maintaining the system was slow and inefficient.”

CHPW decided to outsource claims and payments to a third party and engaged Dell Services to help. Dell Services would operate a software-as-a-service (SaaS) administrative platform for claims and billing functions, as well as provide the backend infrastructure to provider and member portals. Dell Services also covered data entry, mailroom services, claims processing, configuration services and premium billing.

Frustration mounts

During the transition, however, data accuracy became a problem and a backlog of many tens of thousands of claims quickly grew. “Although our providers were patient, they needed their funds so they can keep their doors open and care for our patients,” says Julie Keeffe, CHPW’s director of exchange strategy and implementation.

As the claims backlog grew, Dell Services deployed an electronic workflow management system, which captures and processes electronic data and drives work to specific individuals or teams using automated routing. The system also tracks contractual details and other data that affect payment processing.

Speed counts

The workflow system cut claims-processing time while boosting payment turnaround speed and accuracy. CHPW’s backlog dropped from 172,000 claims to less than 70,000 until reaching today’s baseline inventory of 35,000 claims. Other benefits include:

  • Ability to compete and grow membership
  • Agility and ability to scale for new markets
  • Increased reputation among providers and state regulators

Today, CHPW’s claims processing not only helps keep providers happy, but also is recognized by state regulators as a model for other Medicaid-focused plans. Chief administrative officer Alan Lederman says the state relied upon CHPW to help identify potential issues and to help solve problems.

“But aside from improving our business operations, we’re improving the health of our members, with Dell as our strategic partner,” he says.

Watch how Dell Services worked with CHPW

Click to watch video about how Dell Services worked with Community Health Plan of Washington

Taking the next steps

Implementing a business process outsourcing arrangement can help provide increased claims throughput and performance, reduce predictable costs, and provide greater visibility—just as CHPW has done.

Read more about how CHPW achieved all of these benefits in the full CHPW case study.

Have a claims-processing headache? Dell Services can help. As a leader in health plan-focused services, Dell’s BPO services processes more than 96 million claims, handles more than 11 million call center inquiries, and manages $3.6 billion in premium revenues per year. 

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